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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412147
Report Date: 09/09/2022
Date Signed: 09/09/2022 12:46:06 PM

Document Has Been Signed on 09/09/2022 12:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDLUXURY VILLAFACILITY NUMBER:
336412147
ADMINISTRATOR:LILIBETH GRABOWSKIFACILITY TYPE:
740
ADDRESS:79105 ARBOLA CIRCLETELEPHONE:
(760) 469-3934
CITY:LA QUINTASTATE: CAZIP CODE:
92253
CAPACITY: 6CENSUS: 5DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lilibeth Grabowski - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Lilibeth Grabowski and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:
Infection Control: LPA Colvin with Administrator Lilibeth Grabowski and reviewed the facility's Mitigation Plan. Resident bathrooms were stocked with hand soap, sanitizer, and paper towels. LPA Colvin did not observe any hand washing guides in the three residents bathrooms. LPA Colvin recommended for the Administrator to post hand washing guides in each bathroom. Upon entering the facility, LPA Colvin observed postings for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to be sufficient for a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Lilibeth Grabowski in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE. LPA Colvin observed that the facility has a designated visitation area in the garage which is comfortably furnished, and the garage door is kept open to encourage air flow, for outdoor visitation.

Administrator Lilibeth Grabowski confirmed that all staff have been fit tested, and LPA Colvin suggested to have staff re-fit tested annually. LPA Colvin also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Administrator Lilibeth Grabowski confirmed that staff are continuing to monitor residents’ symptoms, and that both staff and visitors are screened for COVID-19 symptoms prior to entering the facility. LPAs Colvin additionally observed a sign-in log for visitors, where their temperature is recorded as well as answers to screening questions. LPA Colvin observed staff to be wearing face masks, but were not covering their noses. LPA Colvin suggested to the Administrator to remind staff to wear face coverings properly at all times in the facility. An exit interview was conducted with Administrator Lilibeth Grabowski and a copy of this report was provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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